By completing this form I authorize The Pacific Clinic to use and disclose the protected health information described in this assessment to their medical director and necessary team members to aid in my treatment and care at the facility.
This authorization for release of this information covers the period of
all past, present, and future periods.
Pacific Clinic ("PC") assessment form is used to determine the necessity of functional exercise and activities for the physical, emotional and mental well-being of clients. COMPLETING THIS FORM DOES NOT AUTOMATICALLY ENROLL YOU IN A WELLNESS PLAN. PLEASE CALL 509-783-5465 TO SCHEDULE AN APPOINTMENT TO GET ENROLLED.
COVID-19 LIABILITY WAIVER
The health and safety of our members, guests and employees is a top priority for the PC.
I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury (or illness) to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the PC or my participation in PC programming (“Claims”). On behalf of me and my children, I hereby release, covenant not to sue, discharge, and hold harmless the PC, its owners, employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto.
I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the PC, its owners or employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after my participation in any PC usage, lesson, class, or program.
